RESUMO
Invasive fungal disease (IFD) causes significant morbidity and mortality in patients undergoing allogeneic haemopoietic stem cell transplantation or chemotherapy for haematological malignancy. Much of these adverse outcomes are due to the limited ability of traditional diagnostic tests (i.e. culture and histology) to make an early and accurate diagnosis. As persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients despite broad-spectrum antibiotics have been associated with the development of IFD, most centres have traditionally administered empiric antifungal therapy (EAFT) to patients with PFUO. However, use of an EAFT strategy has not been shown to have an overall survival benefit and is associated with excessive antifungal therapy use. As a result, the focus has shifted to developing more sensitive and specific diagnostic tests for early and more targeted antifungal treatment. These tests, including the galactomannan enzyme-linked immunosorbent assay and Aspergillus polymerase chain reaction (PCR), have enabled the development of diagnostic-driven antifungal treatment (DDAT) strategies, which have been shown to be safe and feasible, reducing antifungal usage. In addition, the development of effective antifungal prophylactic strategies has changed the landscape in terms of the incidence and types of IFD that clinicians have encountered. In this review, we examine the current role of EAFT and provide up-to-date data on the newer diagnostic tests and algorithms available for use in EAFT and DDAT strategies, within the context of patient risk and type of antifungal prophylaxis used.
Assuntos
Aspergilose/prevenção & controle , Candidíase/prevenção & controle , Febre de Causa Desconhecida/microbiologia , Neoplasias Hematológicas/imunologia , Transplante de Células-Tronco Hematopoéticas , Profilaxia Pré-Exposição , Algoritmos , Antifúngicos/uso terapêutico , Consenso , Estado Terminal , Esquema de Medicação , Medicina Baseada em Evidências , Febre de Causa Desconhecida/tratamento farmacológico , Neoplasias Hematológicas/complicações , Neoplasias Hematológicas/terapia , Humanos , Hospedeiro Imunocomprometido , Reação em Cadeia da Polimerase , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND: The off-label use of a drug refers to a use outside the terms of its approval by the Therapeutic Goods Administration (TGA). It is also possible to prescribe unlicensed drugs under the TGA's special access scheme. A high rate of off-label prescribing has previously been reported in cancer. Our study aimed to document the disparity between evidence-based clinical guidelines for anticancer therapy, product approval and funding status of these agents within an academic tertiary/quaternary cancer centre. METHODS: All chemotherapy protocols approved for use in our specialist oncology centre were assessed to determine if the drugs were off-label or unlicensed for that indication based on review of their current product information. The Pharmaceutical Benefits Scheme (PBS) funding status for each protocol was subsequently assessed. RESULTS: A total of 448 protocols containing 82 different drugs across 15 tumour groups was identified. Overall, 189 (42.2%) of protocols were off-label, and three (0.7%) were unlicensed. This resulted in all 192 protocols being unfunded by the PBS. Of the 189 off-label protocols, 132 (69.9%) were based on established evidence-based treatment guidelines, and a further 39 (20.6%) was based on phase II or III clinical trial data. CONCLUSION: Over 90% of off-label protocols are supported by established treatment guidelines or published peer-reviewed research even though the medications are not approved for that particular use by the TGA. However, these off-label protocols are unfunded by the PBS; this results in a marked inequality of access to appropriate medications for cancer patients across Australia.
Assuntos
Antineoplásicos/provisão & distribuição , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Seguro de Serviços Farmacêuticos , Neoplasias/tratamento farmacológico , Uso Off-Label/estatística & dados numéricos , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/estatística & dados numéricos , Antineoplásicos/economia , Institutos de Câncer/economia , Institutos de Câncer/estatística & dados numéricos , Protocolos Clínicos , Aprovação de Drogas , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Medicina Baseada em Evidências , Financiamento Governamental , Fidelidade a Diretrizes , Humanos , Seguro de Serviços Farmacêuticos/economia , Neoplasias/economia , Uso Off-Label/economia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Fatores Socioeconômicos , Centros de Atenção Terciária/economia , Centros de Atenção Terciária/estatística & dados numéricos , VitóriaRESUMO
The current consensus guidelines were developed to standardize the clinical approach to the management of neutropenic fever in adult cancer patients throughout Australian treating centres. The three areas of clinical practice covered by the guidelines, the process for developing consensus opinion, and the system used to grade the evidence and relative strength of recommendations are described. The health economics implications of establishing clinical guidance are also discussed.
Assuntos
Antibacterianos/uso terapêutico , Febre/tratamento farmacológico , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Neoplasias/complicações , Neutropenia/complicações , Adulto , Assistência Ambulatorial , Antineoplásicos/efeitos adversos , Austrália , Infecções Bacterianas/complicações , Infecções Bacterianas/tratamento farmacológico , Institutos de Câncer/normas , Conferências de Consenso como Assunto , Análise Custo-Benefício , Coleta de Dados , Febre/economia , Febre/etiologia , Hospitalização , Humanos , Hospedeiro Imunocomprometido , Neoplasias/tratamento farmacológico , Neoplasias/economia , Neutropenia/induzido quimicamente , Neutropenia/economia , Padrões de Prática Médica , Fatores de RiscoRESUMO
BACKGROUND: Although the incidence of neutropenic fever (FN) is estimated to be up to 80% for some malignancies, the epidemiological characteristics and economic burden are not well understood for Australian patients. AIMS: To describe underlying malignant conditions, potential aetiologies, clinical outcomes and healthcare utilization for an Australian population with FN, and to estimate the economic burden of this condition within the Australian healthcare sector. METHODS: Epidemiological features of FN were extracted from a population-based hospital morbidity dataset, the Victorian Admitted Episodes Dataset (VAED), for a 12-month period (2008). These were analysed according for a range of malignancy categories. Economic burden of hospitalizations was estimated according to data presented in the Round 12 National Hospital Cost Data Collection Report. RESULTS: A total of 2599 admitted episodes across 92 Victorian hospitals fulfilled inclusion criteria for FN. Metropolitan hospitalizations accounted for 79% episodes. FN illness comprised underlying solid tumours diagnoses (40%), followed by leukaemia (29.3%), lymphoma (22%) and myeloma (8.5%). Length of hospital stay was >15 days for approximately one-third of hospitalizations. intensive care unit admission rates were 5.9-11.7%. Weighted average costs of hospitalization (AUD) for solid tumours, lymphoma, myeloma and leukaemia were $8309 ± $391, 18,145 ± $1602, $21,764 ± $1289 and $22,596 ± $2618 respectively. CONCLUSIONS: Using VAED indices, epidemiological features of Australian patients with FN appear comparable with international reports. In contrast to US data, estimated healthcare costs are up to 50% lower in the Australian healthcare sector. These data offer important insights for prioritizing of research agendas and resource allocation.
Assuntos
Institutos de Câncer/estatística & dados numéricos , Febre/tratamento farmacológico , Custos Hospitalares/estatística & dados numéricos , Neoplasias/complicações , Neutropenia/complicações , Adulto , Anti-Infecciosos/economia , Anti-Infecciosos/uso terapêutico , Infecções Bacterianas/complicações , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/economia , Infecções Bacterianas/epidemiologia , Custos e Análise de Custo , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Infecção Hospitalar/complicações , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/economia , Infecção Hospitalar/epidemiologia , Bases de Dados Factuais , Grupos Diagnósticos Relacionados , Febre/economia , Febre/epidemiologia , Febre/etiologia , Hospitalização/economia , Humanos , Incidência , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Micoses/complicações , Micoses/tratamento farmacológico , Micoses/economia , Micoses/epidemiologia , Neoplasias/tratamento farmacológico , Neoplasias/economia , Neoplasias/epidemiologia , Neutropenia/induzido quimicamente , Neutropenia/economia , Neutropenia/epidemiologia , Prevalência , Vitória/epidemiologiaRESUMO
BACKGROUND: An abundance of new evidence regarding treatment strategies for neutropenic fever is likely to contribute to variability in practice across institutions and clinicians alike. AIMS: To describe current clinical practices in Australia, by surveying haematologists, oncologists and infectious diseases physicians involved in cancer care. METHODS: Clinician members from Australian professional associations, accounting for the vast majority of Australian cancer specialists, were invited to participate in an electronic survey, comprising of a clinical case-based questionnaire. Clinical practice areas explored were: use of risk-assessment and empiric antibiotic strategies across various treatment settings; use of anti-bacterial prophylaxis; and use of granulocyte-colony stimulating factors for established neutropenic fever and for secondary prophylaxis. RESULTS: A total of 252 clinicians returned responses (approximately 30% response rate). The majority (>70%) were representative of practices in public, major city, tertiary referral hospitals. Less than half of clinicians were aware of risk-assessment tools and less than quarter currently used ambulatory care strategies. If adequate resources were made available, more than 80% were willing to use risk-assessment tools and 60% more clinicians were likely to use ambulatory care strategies. Most clinicians prescribed dual therapy parenteral antibiotics, even for clinically stable patients (53% haematologists, 56% oncologists). Granulocyte-colony stimulating factor was used frequently as secondary prophylaxis in the breast cancer case (91%), follicular lymphoma case (59%) and non-small cell lung cancer case (31%). Fluoroquinolone prophylaxis was infrequently prescribed (19% oncologists, 30% haematologists). CONCLUSIONS: Evidence-practice gaps were identified around the use of risk-assessment-based empiric therapy, and help to inform better clinical guidance.
Assuntos
Uso de Medicamentos/estatística & dados numéricos , Febre/tratamento farmacológico , Neoplasias/complicações , Neutropenia/complicações , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Assistência Ambulatorial , Antibioticoprofilaxia/estatística & dados numéricos , Austrália/epidemiologia , Infecções Bacterianas/complicações , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/epidemiologia , Institutos de Câncer/organização & administração , Institutos de Câncer/estatística & dados numéricos , Coleta de Dados , Medicina Baseada em Evidências , Febre/epidemiologia , Fator Estimulador de Colônias de Granulócitos/administração & dosagem , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Hematologia , Hospitalização , Humanos , Infectologia , Oncologia , Neoplasias/epidemiologia , Neutropenia/tratamento farmacológico , Neutropenia/epidemiologia , Sociedades Médicas , Inquéritos e QuestionáriosRESUMO
Persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients on broad-spectrum antibiotics have traditionally been treated with empirical antifungal therapy (EAFT). The lack of survival benefit seen with the use of amphotericin B deoxycholate (AmB-D) as EAFT has been attributed to its toxicities. More recently, newer, less toxic and more expensive antifungal agents such as the lipid formulations of AmB, the newer azoles (fluconazole, itraconazole and voriconazole) and caspofungin have been analysed in a number of EAFT trials. Compared with AmB-D the newer agents have superior safety but are of equivalent efficacy. This lack of survival advantage is related to the fact that the trigger for commencement of EAFT is late and non-specific. Thus, alternative approaches are required. New sensitive serological and molecular tests for the detection of Aspergillus antigens and genomic DNA have been developed and evaluated in accuracy studies. These tests have been incorporated into management strategies (i.e. pre-emptive strategies) to direct antifungal therapy. The pre-emptive approach has been shown to be safe and feasible but its impact on clinically important patient outcomes such as survival is less clear. Other advances include the introduction of effective, non-toxic mould-active antifungal prophylaxis and patient risk-group stratification. In this paper we provide new evidence-based algorithms for the diagnosis and treatment of PFUO in adult patients undergoing stem cell transplantation and chemotherapy for haematological malignancy which incorporate these newer diagnostic tests and are directed by the risk category of the patient and type of antifungal prophylaxis the patient is receiving.
Assuntos
Antifúngicos/uso terapêutico , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/tratamento farmacológico , Transplante de Células-Tronco , Adulto , Algoritmos , Antígenos de Fungos/análise , Aspergillus/imunologia , Aspergillus/isolamento & purificação , Medicina Baseada em Evidências , Galactose/análogos & derivados , Humanos , Leucemia/complicações , Mananas/análise , Reação em Cadeia da Polimerase , Recidiva , Tomografia Computadorizada por Raios X , beta-Glucanas/análiseRESUMO
STUDY DESIGN: Retrospective review of patient data. OBJECTIVE: To present two years of experience in the use of gabapentin for the alleviation of neuropathic pain in spinal cord injury patients. SETTING: Supra-regional Spinal Cord Service, Melbourne, Australia. METHOD: Data were retrieved from the medical records of all spinal cord injury patients prescribed gabapentin for neuropathic pain. Pain was assessed prior to and during treatment at 1, 3 and 6 months with a 10 cm visual analogue scale which ranged from 0 ('no pain') to 10 ('worst pain imaginable'), or by the documentation of a verbal description of pain. RESULTS: Seventy-six per cent of patients receiving gabapentin reported a reduction in neuropathic pain. In those patients with data at all four measurement points, the mean pretreatment score was 8.86. Following treatment with gabapentin the score dropped to 5.23, 4.59 and 4.13 at 1, 3 and 6 months, respectively. Where only a verbal description of pain was documented, the trend was that the pretreatment report of 'unbearable' was replaced by 'liveable' during treatment. CONCLUSION: Our experience suggests that gabapentin offers an effective therapeutic alternative for the alleviation of neuropathic pain following spinal cord injury. Controlled clinical trials are now required to confirm these observations.